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Statement Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases
Han Hee Lee1,*orcid, Jin Su Kim2,*orcid, Hyeon Jeong Goong3orcid, Shin Hee Lee4orcid, Eun Hye Oh5orcid, Jihye Park6orcid, Min Cheol Kim7orcid, Kwangwoo Nam8orcid, Young Joo Yang9orcid, Tae Jun Kim10orcid, Seung-Joo Nam11orcid, Hee Seok Moon12orcid, Jae Hyun Kim13orcid, Duk Hwan Kim14orcid, Seong-Eun Kim15orcid, Seong Ran Jeon16,orcid, Seung-Jae Myung17,orcid, The Small Intestine Research Group of the Korean Association for the Study of Intestinal Diseases (KASID)
Intestinal Research 2023;21(1):3-19.
DOI: https://doi.org/10.5217/ir.2022.00108
Published online: January 31, 2023

1Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

2Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

3Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea

4Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea

5Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea

6Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea

7Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea

8Department of Gastroenterology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea

9Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea

10Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

11Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea

12Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea

13Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea

14Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea

15Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea

16Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea

17Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to Seung-Jae Myung, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3917, Fax: +82-2-476-0824, E-mail: sjmyung@amc.seoul.kr
Co-Correspondence to: Seong Ran Jeon, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-Gu, Seoul 04401, Korea. Tel: +82-2-709-9202, Fax: +82-2-709-9581, E-mail: 94jsr@hanmail.net
*These authors contributed equally to this work as first authors.
*This article is co-published by Intestinal Research (in English) and The Korean Journal of Gastroenterology (in Korean) to facilitate widespread distribution.
• Received: August 22, 2022   • Revised: October 7, 2022   • Accepted: November 12, 2022

© Copyright 2023. Korean Association for the Study of Intestinal Diseases

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.
  • Keywords: Device-assisted enteroscopy; Balloon enteroscopy; Intestine, small; Consensus statement
Evaluation of the small bowel (SB) has long been a challenge for endoscopists because of its location and length. Endoscopic instruments have made remarkable progress in overcoming this challenge, with 2 revolutionary enteroscopic procedures, capsule endoscopy (CE) and device-assisted enteroscopy (DAE), which appeared at the beginning of the 21st century, completely changing the paradigm of managing SB diseases [1,2].
Unlike CE, DAE has both diagnostic and therapeutic abilities and has a unique advantage in situations such as small bowel bleeding (SBB). Three types of DAE are currently available: double-balloon enteroscopy (DBE), single-balloon enteroscopy (SBE), and spiral enteroscopy. The main technical and performance parameters, such as depth of insertion, learning curve, complications, diagnostic yield, and therapeutic yield, are known to be comparable among the 3 methods [3].
In Korea, DAE has been reimbursed by the National Health Insurance since August 2014. Although DAE has been incorporated into daily practice, there are no proper recommendations providing useful guidance for the DAE procedure. For this reason, the Small Intestine Research Group of the Korean Association for the Study of Intestinal Diseases (KASID) decided to develop a set of consensus statements for DAE to ensure that it is performed properly in clinical practice.
We intended to draw up these statements by placing greater emphasis on the following 3 purposes: First, the statements should provide guidance regarding the indication, timing, and performance of DAE for various clinical situations. Second, it is necessary to suggest what should be considered for a successful procedure. Third, DAE-related complications and how to manage them should be informed. These statements consist of 3 sections: Preprocedure, Intraprocedure, and Postprocedure. These statements do not have precedence over clinical evaluations made by physicians that consider various factors related to the patients and health care environment in actual clinical practice. Therefore, these statements must not be used to restrict the medical practice of clinicians or to make legal judgments regarding DAE procedures or treatments performed on a particular patient. Nevertheless, these statements are expected to serve as a useful and complementary reference in clinical settings.
The expert statement committee consisted of the president (Seung-Jae Myung) and committee members of the Small Intestine Research Group of KASID, which comprised 16 expert endoscopists in the field of DAE in July 2020. The committee reviewed published articles and guidelines regarding DAE for SB diseases and developed the initial statements. Sixteen statements were drafted after discussion and revision. The statements were grouped into 3 parts: Preprocedure, Intraprocedure, and Postprocedure.
The modified Delphi method was applied to establish an expert statement [4,5]. A 9-point Likert scale questionnaire (range 1–9; 1=strongly disagree, 9=strongly agree) with a literature review of supporting data was provided by e-mail to the panel of 17 endoscopists with expertise in DAE and SB diseases. A statement was accepted if the coefficient of variation was less than 0.5. Initially, all 16 statements met the criteria for the coefficient of variation. However, if a small number of panelists requested correction, the development committee reviewed and revised the statements according to the panelists’ comments and then requested a review of the revised statements from the panelists. Two rounds of modified Delphi exercises were conducted, a final draft of 15 statements was made after revision based on this process. Table 1 summarizes the statements with strength of agreement among panelists.
The current statements for use in clinical settings will be subject to revision by systematic review in the future.
1. Preprocedure

1) Preprocedural Indications

(1) Small bowel bleeding

Statement 1
Diagnostic yield can be increased by performing DAE after CE in overt and occult suspected small bowel bleeding (SSBB). DAE can be considered following CE or contrast-enhanced computed tomography (CT) in overt and occult SSBB.
Obscure gastrointestinal bleeding is defined as gastrointestinal bleeding of unknown cause even after upper and lower gastrointestinal endoscopy. Obscure gastrointestinal bleeding accounts for approximately 5% of gastrointestinal bleeding and is usually due to SBB [6]. CE is useful for the detection of a source of SSBB, except for hemodynamically unstable patients with massive bleeding requiring emergency angiography [7,8]. Contrast-enhanced CT can be considered instead of CE in patients with suspected obstruction [7,8]. The most common indication for DAE is diagnostic evaluation of and therapeutic procedures for SSBB. DAE could be indicated as a diagnostic procedure for negative/positive results of CE or contrast-enhanced CT and as the first-line therapeutic procedure for positive results of CE or contrast-enhanced CT [7,8].

Overt SBB

Overt SBB patients presenting with either melena or hematochezia require definitive diagnosis because of morbidity and mortality with ongoing bleeding [9]. In a meta-analysis, the diag nostic yield of CE was higher than that of DAE, and could be increased by performing DAE after CE [10]. The diagnostic yield of DAE in overt SBB patients has been reported at 68.5% to 100% [11-18]. The diagnostic yield of DAE in ongoing overt SBB patients is higher compared to those with previous overt SBB or occult SBB [11-14,19]. Therefore, if ongoing overt SBB is suspected, DAE should be considered as the preferred therapeutic procedure following CE with a positive result. The therapeutic yield of DAE in overt SBB patients has been reported at 33.3% to 77.8% [17,18,20-23]. Following endoscopic therapy with DAE, the absolute rebleeding rates of SBB are high, reported to be 33.1% to 60.0% [24-26]. The long-term rebleeding outcome of overt SBB patients after DAE at 12 months has been found to be 34% compared with 13% in occult SBB patients (P=0.06) [13].

Occult SBB

Occult SBB patients usually visit hospitals for positive fecal occult blood tests or anemia caused by chronic gastrointestinal blood loss [8,27]. The diagnostic yield of DAE in occult SBB ranges from 52.4% to 75.0% [28-30], which increases when DAE is performed after a positive CE [29]. The most frequently identified lesions are angioectasias, and occasionally, erosions, ulcers, and tumors [29,30]. Although previous studies did not comparatively evaluate therapeutic yields between overt and occult SBB, therapeutic yields of SBB, defined as improved hemoglobin levels and decreased transfusion needs after hemostatic procedures during DAE, were reported as substantial [31-33]. Liver cirrhosis, female sex, Osler-Weber syndrome, and cardiac disease were reported to be factors associated with rebleeding [33,34].
Statement 2
In cases of overt SSBB, early DAE can be considered after CE or contrast-enhanced CT to improve diagnostic yield and provide a chance for therapeutic intervention.
Until now, there has been no consensus regarding the most appropriate timing of DAE in overt SBB [8]. In most clinical practice, CE or contrast-enhanced CT precedes DAE unless there is massive hemorrhage, and if the bleeding lesion is identified, DAE is recommended to confirm and treat the lesion [6,7]. Previous guidelines recommended CT enterography (CTE) as a proper imaging study for SSBB [6-8], but contrast-enhanced CT could also be acceptable for the initial evaluation of SSBB in general situations [35]. Like the proper timing of CE in SSBB [36], proper timing of DAE after bleeding episodes is important to increase diagnostic and therapeutic performance. In a previous study, diagnostic yield for SSBB was found to be higher when CE was performed within 7 to 15 days compared to CE performed after 7 to 15 days, and within 1 month compared to that after 1 month [35]. Urgent DAE, which is performed within 72 hours from the onset of SSBB, showed not only higher diagnostic yield compared to non-urgent intervention (70%–90% vs. 30%–50%, respectively), but also higher therapeutic performance (28.6%–57.5% vs. 13.0%–50.0%, respectively) [37]. Another study reported that DAE within 24 hours in overt SBB showed a higher diagnostic (70%) and therapeutic yield (90%) [20]. In a recent meta-analysis of DAE in overt bleeding, early DAE was associated with a significantly higher diagnostic yield (odds ratio, 3.2; 95% confidence interval, 1.9–5.3; P=0.002), although the definition of early intervention varies among the studies (from during ongoing bleeding to 1 week) [38]. These studies sug suggest that early DAE may increase diagnostic yield and improve treatment outcomes, although the definition of early or urgent intervention is not unified. The reason for the increase in the diagnostic yield in early DAE is hypothesized as follows. Vascular lesions, such as angioectasia or Dieulafoy lesions in the SB, are usually too small to be detected during enteroscopic procedures. If such a lesion shows active bleeding during the procedure, it can more easily be found and the opportunity is presented to treat endoscopic hemostasis. However, if bleeding temporarily stops, it is difficult to identify the definite site of bleeding. Yin et al. [18] reported a study of emergency enteroscopy, supporting this hypothesis. They divided the enrolled patients (n=265) into 3 groups according to the timing of the procedure: less than 3 days (n=32), between 3 and 7 days (n=146), and >7 days (n=87). The reasons for bleeding included angioectasia, diverticulum, tumor, ulceration/erosion, and polyps. The ratio of diagnostic findings between the 3 groups was not different except for angioectasia, which showed increased yield in the emergency setting (<3 days) compared to the other groups (3–7 days or >7 days). Considering the bleeding pattern of vascular lesions in the SB, emergency enteroscopy could increase the diagnostic yield, which gives endoscopists more opportunities to perform endoscopic hemostasis. Considering the above results, in the case of overt SSBB, early DAE could increase the diagnostic yield and provide a chance for therapeutic intervention.

(2) Crohn’s disease

Statement 3
DAE is not a routine diagnostic test in patients with clinical-ly suspected Crohn’s disease (CD). However, if there is no specific finding in the ileo-colonoscopy or other imaging studies, and results of laboratory tests alone are insufficient to diagnose CD in patients with suspected SB CD, SB tissue biopsy through DAE can be considered for enhancing con-firmative diagnosis.
Thirty to sixty percent of patients with CD have SB lesions, and 10% to 30% of patients show isolated SB disease. Isolated SB CD is difficult to diagnose because the lesion cannot be identified using duodenoscopy and colonoscopy only, which are standard endoscopy methods [39,40]. Since SB CD often progresses to complicated diseases such as stenosis and can lead to poor clinical outcomes that require surgery, early diagnosis and appropriate management of this SB disease are important.
Although most studies on DAE in CD are small studies, some studies reported that the diagnostic yield in patients with suspected SB CD was low in the early days of DAE introduction, but recently reached 80% [41,42]. Common indications for DAE in patients with suspected CD were abnormal CE or other imaging studies. It is reported that the diagnostic sensitivity of DAE for suspected SB CD is higher than that of other imaging tests such as SB barium contrast studies, CT, or magnetic resonance enterography (MRE) [6,42,43]. The diagnosis of SB mucosal changes by radiographic examination can be misleading, especially in mild forms of SB disease [41]. Although CE is convenient and widely available to detect SB lesions, the statement by the European Crohn’s and Colitis Organisation and the World Endoscopy Organization recommended that a diagnosis of CD should not be based on CE findings alone because there are no validated criteria for CE-based diagnosis of SB CD [44]. A poor correlation between CE and DBE in suspected CD patients has also been reported [41]. Therefore, not only when no specific findings are observed, but even if there is a positive CE finding in patients with known or clinically suspected CD, caution is still needed when interpreting the results. Regardless of CE findings, DAE can be considered as an additional diagnostic tool when it is judged that various imaging tests and laboratory findings are insufficient to diagnose clinically suspected small intestine CD.
Unlike other imaging modalities such as CT or MRE and CE, the advantage of DAE in patients with suspected CD is that it is possible to obtain tissue samples for pathologic diagnosis. Furthermore, it is possible to perform endoscopic therapeutic interventions such as stricture dilation and landmarks or tattooing of lesions, as well as avoiding the risk of capsule retention [45]. The rate of granuloma diagnosis has been reported as 6.3% to 39% in SB pathology results obtained by DAE [41,42,46].
However, despite these advantages to increase the diagnostic yield, it is difficult to routinely perform DAE in all patients with suspected SB CD. This is because DAE is an invasive examination, requires advanced skills, and is a time-consuming study, in addition to the fact that DAE availability (examination environment and expertise of the examiners) varies by institution [47]. In some cases, the clinical condition of the patient or the location of the lesion does not permit this invasive procedure.
Complications are known to be rare and occur in <1% of diagnostic DAE cases; however, they may be higher in patients with active CD [6,48]. In a systematic review, the per-procedure perforation rate of diagnostic DAE in CD was similar to diagnostic DAE for all indications [49]. However, the perforation risk was higher if an intervention was carried out. Balloon dilation of strictures has a reported perforation risk of up to 3% [45,49,50]. If the patient has fixed bowel secondary to active CD or adhesions from previous surgeries as well as strictures, the procedure becomes more difficult, and deep intubation of the scope is limited. In 17% of CD patients the DAE procedure was unable to reach the target area [41]. In addition, it should be noted that the predicted complication rates from endoscopists with less experience might be higher since most of the reported complication rates use data from experienced endoscopists [51].
In conclusion, although DAE is not a routine diagnostic tool in patients with clinically suspected CD, it can be considered for histologic confirmation of suspected CD imaging findings or CD observed only in the SB without lesions in the gastro-colorectal area. DAE can also be reserved for potential therapeutic interventions, such as dilation of stenosis.

(3) SB tumor

Statement 4
DAE can be considered for the localization and character-ization of SB tumors along with other imaging modalities.
Previously, the barium SB series was the initial screening method to detect SB tumors, with a diagnostic rate of only 30% to 44% [52,53]. This modality is no longer preferred due to the introduction of newer technologies. A combination of contrast-enhanced CT and CE is useful for detecting SB tumors [54]. CTE in particular allows intraluminal visualization, which can help determine the stage of SB tumors. However, CT has a low diagnostic yield for epithelial tumors in the SB, and CE could miss tumors located in the distal duodenum and proximal jejunum (because CE passes quickly through this area) [54-56]. MRE could also be a useful tool for detecting SB tumors, but this modality has some limitations, including high costs, lack of availability, and contraindications in patients with metal devices such as pacemakers [57].
The diagnostic yield of DAE for SB tumors is comparable to that of a combination of CT and CE [58,59]. The overwhelming advantage of DAE is that it can be used for histologic diagnosis and endoscopic treatment. A multicenter retrospective analysis in Japan described that SB tumors were identified by DAE in 61 of 144 subjects (42.4%) who suspected the presence of SB tumors for 5 years; malignant lymphoma was most frequent (31/144, 21.5%) and gastrointestinal stromal tumor (GIST) was the second most frequent (27/144, 18.8%) [60,61].
Based on these results, we suggest that DAE can be considered a useful tool for the detection and characterization of SB tumors along with other imaging modalities.
Statement 5
DAE may be used in symptomatic patients with intestinal polyposis causing obstruction and bleeding. Also, DAE may be used for the diagnosis and follow-up of some intestinal polyposis syndromes, particularly Peutz-Jeghers syndrome (PJS) rather than familial adenomatous polyposis (FAP).
Intestinal polyposis syndromes are relatively rare and can be classified into hamartomatous polyposis syndromes, FAP, and other rare polyposis syndromes such as hereditary mixed polyposis syndrome. SB polyps occur in 90% of PJS patients characterized by hamartomatous polyposis, and in more than 75% of those with FAP [62]. FAP patients with duodenal polyps are at significantly higher risk to exhibit additional polyps in more distal parts of the SB.
A retrospective study analyzing the correlation between CE and DAE in 25 patients with SB polyps showed that the agreement between CE and DAE was good for both the location and size of polyps, but DAE was better than CE in defining the number of polyps [63]. Another retrospective study including 18 patients with PJS who underwent fluoroscopic enteroclysis showed that the polyp detection rate of DAE was better than that of fluoroscopic enteroclysis and similar to that of CE [64]. A prospective study of 15 patients with PJS who underwent both MRE and DAE showed that MRE and DAE have a comparable diagnostic yield for detecting clinically relevant SB polyps (≥15 mm), but DAE allows for direct interventions such as immediate polypectomy, tattooing, and biopsy, and was preferred over MRE by most patients [65].
In patients with PJS, large polyps (10–15 mm) or symptomatic or rapidly growing polyps should be removed because these polyps are risk factors for SB intussusception [66]. DAE proved to be safe and effective in the treatment of SB polyps in patients with PJS in various studies, and the resection of SB polyps through DAE resulted in a significant decrease in the mean number and mean maximum size of resected polyps in periodic enteroscopies [67-69]. Additionally, a multicenter retrospective cohort study of 25 patients with PJS reported that there were no SB polyp-related complications at a median follow-up of 56.5 months after polypectomy of SB polyps by DAE [68]. However, the effect of DAE therapy on cancer reduction remains unknown.
There is still insufficient evidence regarding the indications for or role of DAE in patients with FAP. A study on the prevalence of SB adenomas in 41 patients with FAP reported that DAE is equal to intraoperative endoscopy in terms of diagnostic yield for SB adenomas in FAP [70]. A prospective study of 62 patients with FAP showed that screening and surveillance with DAE could be useful in FAP patients with advanced duodenal polyposis. However, another study of 18 FAP patients with advanced duodenal polyposis reported that routine DAE is not warranted in patients with FAP because the malignant potential of these lesions is unknown [71,72].
Statement 6
In patients with suspected SB tumors, DAE can be consid-ered for definite histologic diagnosis, identification of the extent and location of SB tumors, and therapeutic interven-tions to tailor appropriate treatment strategies.
If there is uncertainty about the diagnosis and therapeutic strategies for SB tumors, or subepithelial tumors are detected in CE or other imaging modalities, DAE is a useful procedure to elucidate definite histologic diagnosis through direct visualization of SB mucosa [73-75]. Previous studies showed that DAE enables histologic diagnosis in the majority of patients with SB tumors and the diagnostic yield is high for adenocarcinoma, lymphoma, and neuroendocrine tumor (NET) [54,60,76]. However, in patients with highly suspicious GIST, histologic confirmation through tissue biopsy should be chosen with care because 50% to 80% of the DAE biopsies for GIST missed the diagnosis and the hypervascular nature increased bleeding risk after biopsy [58,60,77].Therefore, in the case of GIST, tissue biopsy at the internal margin of ulceration and prophylactic procedures to prevent significant bleeding are recommended [78].
DAE helps identify tumor extent through direct exploration of the entire SB and precisely localizing SB tumors with tattooing. Gangi et al. [79] reported bidirectional DAE found additional NETs in 51.1% of patients who were already diagnosed with SB NETs. In addition, DAE can identify multiple lesions in more than half of patients with metastatic SB tumors and preoperative tattooing effectively marks target lesions and assists in deciding on the most suitable type of operation, facilitating removal of all metastatic SB tumors [80]. DAE is also used to perform other therapeutic interventions, including polypectomy for epithelial tumors within the mucosal layer or subepithelial tumors confined to the submucosal layer, hemostasis for tumor bleeding, and dilatation or stenting for SB obstruction [35,60,81,82]. This is despite some hurdles including limited working channel of the enteroscope and the requirement for high-level technical skills. These procedures revised therapeutic strategies in 25% to 65% of patients with SB tumors by reducing emergent surgery or by modifying the surgical approaches, which suggested beneficial impacts on clinical practice for SB tumors [73,83].

2) Preprocedural Considerations

Surgically altered anatomy

Statement 7
In surgically altered anatomy, DAE enables examinations of parts of the intestinal lumen that are inaccessible to conven-tional and CE approaches and facilitates endoscopic retro-grade cholangiopancreatography (ERCP).
Although CE is recommended as the first diagnostic option for SBB, CE cannot reach the bypassed parts of the gastrointestinal tract (e.g., Roux-en-Y gastrojejunostomy) in patients with surgically altered anatomy. In such cases, DAE has the advantage that it can be advanced to a bypassed lumen of the postoperative reconstructed intestine [84-86]. DAE also can be used when SB stricture or obstruction is suspected, for which CE is contraindicated. For this reason, it is recommended that DAE be considered as the initial SB diagnostic procedure in patients with SSBB and possible obstruction or surgically altered anatomy [8].
DAE has increased the success rate of ERCP in patients with anatomical alterations that do not allow access to the pancreaticobiliary system with conventional endoscopy due to upper gastrointestinal surgery [87]. In a systematic review that analyzed the efficacy and safety of DAE-assisted ERCP, the overall ERCP success rate for various post-surgical upper gastrointestinal anatomical configurations was 74% [88]. The success rates were highest at 90% in patients with Billroth II anatomy and lowest at 70% in patients with Roux-en-Y gastric bypass anatomy.
Despite these advantages, it should be cautioned that the risk of perforation might be increased in patients with surgically altered anatomy. In a retrospective study analyzing 2,478 DBE examinations in 9 U.S. centers, the perforation rate was 0.4% (11/2,478) [89]. On the other hand, in the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 3% (7/219), which was significantly higher compared with those without surgically altered anatomy. Six of the seven perforations occurred during transanal DBEs.
2. Intraprocedure

1) Insufflation

Statement 8
The use of carbon dioxide insufflation rather than air insuf-flation improves intubation depth and increases patient convenience.
Insufflation with carbon dioxide (CO2) is reportedly effective in enteroscopic examinations and procedures. An excessive amount of air in the bowel prevents the shortening procedure, making it difficult to insert the endoscope deeper and increasing patient inconvenience. CO2 insufflation dissolves in water at a rate more than 100-fold higher than air and is rapidly absorbed and exhaled through the breath [35]. A randomized, controlled, double-blind trial showed that compared with air insufflation, CO2 insufflation significantly increased intubation depth of transoral enteroscopy in DBE [90]. Another randomized, controlled, double-blind trial reported that CO2 insufflation improves the intubation depth and total enteroscopy (TE) rate in SBE [91]. However, a systematic review and meta-analysis showed that intubation depth of transanal enteroscopy was not significantly different between the CO2 group and the air group [92]. Therefore, CO2 insufflation allows for deeper intubation of transoral DAE and increases the TE rate [90-92]. In addition, compared with air insufflation, CO2 insufflation significantly reduced the sedation dosage during DAE and the degree of abdominal pain after DAE [92,93]. In terms of CO2 retention, 2 randomized controlled trials confirmed that partial pressure of CO2 in the blood did not differ significantly between the CO2 group and the air group [91,93].
Therefore, insufflation with CO2 may lead to a higher diagnostic and therapeutic yield of DAE with reduced patient discomfort and increased safety.

2) Complete Rate

Statement 9
Although the majority of patients with SB lesions can be di-agnosed without TE, TE could be considered in patients with negative CE findings and high clinical suspicion for a signifi-cant SB lesion, or in patients with lesions that are difficult to detect by a single approach.
TE is defined as the complete visualization of the SB with either a single approach alone or combined transoral and transanal approaches. Usually, a combination of transoral and trans anal approaches to achieve TE is required [2]. If TE is needed, tattooing or clipping should be performed at the deepest point that can be reached by a single approach [37]. Then, the marked sites can be accessed by the other route.
In a randomized control trial in Japan, the TE rate of DBE was significantly higher than that of SBE (57.1% vs. 0%, P=0.002) [94]. The result of another randomized control trial performed in Germany was similar (DBE vs. SBE, 66% vs. 22%, P<0.0001) [95]. A systematic review conducted from 2001 to 2010 reported that TE rate for DBE was 44.0% and TE by transoral approach alone was achieved in 1.6% [96]. In 2 studies comparing DBE and SBE, the TE rate for DBE was significantly higher than that for SBE [97,98]. The recently developed motorized spiral enteroscopy increased capability for complete visualization of the SB in a single approach. TE was achieved in spiral enteroscopy using a transoral approach alone (16.6%) and in a combined approach (53.4%) [99].
Although TE rates vary in different DAE techniques, the clinical impact of TE rate remains controversial [100-102]. This suggests that TE rate does not guarantee increased diagnostic or therapeutic yields, as SBE, DBE and spiral enteroscopy have comparable diagnostic and therapeutic yields according to results of previous studies [3,95,103]. In patients with SBB, if a bleeding focus is identified by DAE from either the transoral or transanal approach, TE is not required [104-106]. However, in a study performed in patients with SBB, CE had a significantly lower yield as compared with DBE by combined approaches (odds ratio, 0.12; 95% confidence interval, 0.03–0.52) [107]. The false-negative rate of CE was reported as 11% for all SB lesions and approximately 19% for SB tumors [7]. This suggests that TE can be useful when an SB lesion is strongly suspected. Although the majority of patients with SB lesions can be diagnosed without TE, physicians should consider whether TE should be attempted based on clinical judgment. TE could be considered in patients with a negative CE and a high clinical suspicion of a significant SB lesion [59]. In patients with SB lesions that are difficult to detect by a single approach, TE could also be pursued. In cases of massive SBB where the bleeding site cannot be identified by TE or DAE with combined approaches, radiologic intervention or intraoperative enteroscopy can be considered [108].

3) Insertion Route Choice

Statement 10
The results of diagnostic studies prior to DAE and the clini-cal presentation should be considered in determining the insertion route.
Statement 11
Generally, the transoral approach is the preferred insertion route if the location of the lesion is uncertain from the previous diagnostic investigations. However, the insertion route should be determined considering the overall clinical situation.
DAE is commonly performed following less invasive SB evaluations, such as CE, SB barium contrast studies, CTE, and MRE. Therefore, the results of imaging studies prior to DAE should be considered in the choice of insertion route [8,109,110]. CE transit time has been known to be helpful in determining the insertion route [6]. The transoral approach is preferred due to the deeper intubation and higher success rate if the lesions are suspected to be located in the proximal 2/3 of the SB. Several CE time-based indexes have been suggested; the cutoff value of 0.75 has been proposed which is calculated by the transit time between the ingestion of the capsule and the first image of the lesion divided by the time between ingestion and the first image of the cecum; or the cutoff value of 0.6 has been suggested which is calculated by the time from the pylorus to the lesion divided by the time from the pylorus to the ileocecal valve [7,111-113]. In addition, clinical presentation can be considered in determining the insertion route in case of obscure-overt gastrointestinal bleeding [111]. The transoral approach is preferred in patients with black stool or melena, and the transanal approach is preferred in patients with bright or dark red stool [11,35,37]. In case of massive bleeding, the transoral approach is preferred because of the poor visibility and excessive friction between the scope and overtube by blood and clots in the transanal approach [113].
If no pathology was found through the first insertion route and a whole bowel evaluation is required, approach through the other route after clipping or tattooing the maximal insertion point is recommended in a following session rather than the same session because of the increased insertion depths achieved in a separate session [113,114]. However, in the case of gastrointestinal bleeding, the other route can be tried immediately or as soon as possible, because the diagnostic yield decreases progressively with time [20,35,115].
If the location of the lesion is not revealed by previous examinations, the transoral approach is preferred because of the higher success rate in identifying lesions, especially in patients with SBB [113,116,117]. However, the transanal approach can be considered first in patients with CD or NETs considering the distribution of SB involvement [113].

4) Therapeutic Intervention

(1) Hemostasis

Statement 12
Endoscopic hemostasis is recommended for achieving bleed-ing control and the hemostatic method should be selected according to the bleeding lesion.
DAE has a relatively high therapeutic yield for SBB. A previous prospective study of 60 patients with SBB reported a therapeutic yield of 57% [118]. A recent multicenter retrospective cohort study reported a 67.4% therapeutic yield [119]. In another study considering the timing of endoscopy, earlier enteroscopy had a higher therapeutic yield (100%, 76.9%, and 57.7% at ≤24, ≤48, and ≤72 hours, respectively) [120]. Therefore, endoscopic hemostasis is recommended for various SB lesions such as bleeding lesions (ulcers or erosions), vascular lesions (angioectasia or Dieulafoy lesions), tumors, and diverticula. In addition, there is evidence that endoscopic hemostasis improves clinical outcomes by decreasing transfusion requirements [26,121].
The endoscopic hemostasis method for upper or lower gastrointestinal bleeding can be applied to SBB. The method of endoscopic hemostasis should be selected based on the type of lesion or available treatment tools. Endoscopic hemostasis includes injection therapy with epinephrine, mechanical therapy with hemoclips and band ligation, thermal therapy with argon plasma coagulation, and monopolar or bipolar coagulation [121-123]. As the SB wall is very thin and has a high risk of iatrogenic perforation, argon plasma coagulation or mechanical therapy with hemoclips is recommended for hemostasis of SBB. For bleeding SB polyps, hemostasis can be achieved by endoscopic mucosal resection or polypectomy [123,124]. When endoscopic hemostasis is unsuccessful, surgical treatment or interventional radiology is indicated for ongoing bleeding.

(2) Stricture dilatation

Statement 13
Endoscopic balloon dilatation (EBD) using DAE in symptom-atic benign SB stricture is reasonably safe and effective.
SB strictures occur in cases of CD, nonsteroidal anti-inflammatory drug enteropathy, and post-surgical, idiopathic, and neoplastic lesions. To date, most stricture dilatation procedures using enteroscopy have been performed for CD. Approximately 70% to 80% of patients with CD require surgery due to obstructive symptoms within 20 years after diagnosis, with approximately 30% requiring repeat surgeries within 10 years due to recurrence of symptoms [125]. Repeated surgical treatment can cause short bowel syndrome with other various complications such as fistulae, leaks, and abscesses [126,127]. To prevent such complications, EBD has been used as an alternative procedure to postpone surgery and has shown favorable outcomes with 89% technical success and perforation rates as low as 3% [128]. The usual candidates for EBD are strictures without deep ulceration, without adjacent fistula, and with short segment involvement (≤5 cm) [128]. Until recently, most of the studies were conducted on dilatation of primary strictures (colon and terminal ileum) and anastomotic strictures which were within reach of conventional colonoscopy. However, there are relatively few studies on EBD of SB strictures using DAE. Fukumoto et al. [129] reported a study on the diagnosis and treatment of SB strictures using DAE. EBD using DAE was performed in 23 patients with CD, with a long-term success rate of 73.9% (17/23). In a retrospective cohort study by Sunada et al. [130], 473 stricture EBD procedures using DAE were performed in 85 patients. The surgery-free rates after the stricture dilatation were 87.3% at 1 year, 78.1% at 3 years, and 74.2% at 5 years. In terms of complications, perforations occurred in 4.5% of patients (4/85), and postprocedure bleeding requiring transfusion occurred in 1 patient, which was controlled by endoscopic hemostasis. In the first patient with perforation, mechanical damage after passage of the enteroscope or overtube through the stricture may have been implicated. In the second patient, perforation occurred beyond the reach of the enteroscope, which may be related to increased luminal pressure. In the third patient, dilatation occurred up to 12 mm (stricture diameter before EBD was 5 mm), and in the fourth patient, dilatation occurred up to 15 mm (stricture diameter before EBD was 9 mm). The above complication cases suggest that the maximal or optimal diameter of dilatation usually depends on stricture diameter before EBD, and overtube or enteroscopic mechanical damage should be kept in mind during passage through the dilated stricture. The optimal EBD diameter for SB strictures is still unclear, and further research is needed to draw firm conclusions.
The first multicenter prospective study on the efficacy and safety of EBD using DAE for SB CD strictures was reported by Hirai et al. in 2018 [131]. In this study, a total of 112 patients from 23 institutions were enrolled, and EBD was technically successful in 93.7% of patients (89/95). Short-term success, defined as improvement of symptoms related to stricture within 4 weeks, was achieved in 66 patients (69.5%), while adverse events were low and well-managed with conservative treatment. Recently, a systematic review and meta-analysis were published [132]. In the pooled analysis, the technical success rate was 94.8%, clinical efficacy was 83.3%, and major complications occurred at 1.82% per dilatation and 3.21% per patient. In terms of long-term outcomes, the rate of symptom recurrence was 24.8%, 46.8%, and 67.2% at 6, 12, and 24 months after EBD respectively. Endoscopic redilatation after EBD was observed in 31.2%, 45.7%, and 55.4% of patients within 6, 12, and 24 months respectively. The rate of surgical management after EBD was 22.0% and 24.9% at 12 and 24 months respectively. Considering the above results, EBD using DAE in SB CD strictures is a reasonably safe and effective procedure and postpones the need for surgery when it is applied in cases with appropriate indications.

(3) Polypectomy

Statement 14
Enteroscopic polypectomy is recommended for the removal of large SB polyps to prevent polyp-related complications.
SB polyps larger than 10 to 15 mm may cause bleeding, intussusception, or obstruction [133]. Additionally, in polyposis syndromes such as PJS or FAP, polyps larger than 10 mm are recommended to be resected to prevent malignant transformation [66,134,135]. Before the introduction of enteroscopy, intestinal resection with laparotomy or intraoperative enteroscopy were used for removal of large symptomatic or asymptomatic SB polyps. However, intestinal resection can ultimately result in short bowel syndrome or adhesion, which is more crucial in polyposis syndromes requiring repeated polyp removal. With the development of CE and DAE, the diagnostic and therapeutic efficacy for SB polyps has been reported in a few studies. As most SB polyps arise from polyposis syndrome rather than sporadic polyps, most studies have been conducted in patients with polyposis syndromes. In terms of efficacy, Perrod et al. [136] analyzed 274 polyps that were endoscopically resected by 50 DAEs in 25 patients with PJS. Complete resection was achieved in 76% of cases, and intraoperative enteroscopy and surgical resection were performed in 4 and 2 patients respectively, due to incomplete resection. In a study by Wang et al. [69], after 320 polypectomies in 97 PJS patients, complications occurred in 14 cases (4.4%) including 8 cases of delayed bleeding, 4 perforations, 1 transmural syndrome, and 1 intussusception due to a detained polyp. Mensink et al. [137] conducted a multicenter survey of 2,362 DAE cases, wherein polypectomy-related complications were reported in 12 of 364 polypectomies. In another study by Wang et al. [138], polypectomy-associated complications were reported in 11 of 84 procedures. Considering the results of other small studies, the incidence of complications after enteroscopic polypectomy is reported to be 0% to 13% [67,139-142]. As represented in these studies, most of the complications were minor or moderate bleeding, pancreatitis, and few perforations which could managed by endoscopic or conservative treatment. However, the SB wall is thin and polypectomy during DAE is technically demanding. Therefore, considering the lack of data comparing various endoscopic polypectomy modalities in the SB, it has been suggested that submucosal injection with a dilute solution is required to prevent bleeding or perforation [113].
3. Postprocedure

Complications

Statement 15
Although caution is required according to the patient’s condi-tion and indications, DAE is considered a safe procedure.
The overall complication risk of DAE has been reported as 0.8% to 1% [89,137,143-146], making it a safe procedure. Mortality associated with DAE appears extremely rare [24]. In the case of therapeutic procedures such as dilation, polypectomy, and electrocoagulation, the risk of complications from DAE increases by 1% to 4% [130,144,147]. No difference in complication rate according to patient age or DAE type has been observed [115,148-152]. Major complications of DAE include perforation, bleeding, mucosal injury, and acute pancreatitis. Other minor complications include sore throat, abdominal discomfort, and minimal mucosal injuries.
The incidence of acute pancreatitis in reported studies were 0.3% to 0.5% and almost all cases were in transoral DAE [89,96,137]. Post-DAE pancreatitis is thought to be associated with a long procedure time [153,154]. This might be caused by the physical force applied to the duodenum and pancreas, so balloon inflation and mechanical stress should be minimized in the proximal duodenum during the procedure [155,156]. As described above, the incidence of post-DAE pancreatitis increases in transoral DAE, so caution is needed.
Perforation was generally reported in 0.3% to 0.4% of patients [89,137,156]. However, as mentioned earlier, it should be noted that the perforation risk seems to be higher in patients with al tered anatomy due to abdominal surgery, resection of polyps larger than 30 mm, and SB stricture, so more attention should be paid to these patients [89,113,140].
At the beginning of the 21st century, DBE was introduced as the first form of DAE. Based on technological advances and accumulating evidence of its efficacy, DAE has since gained widespread acceptance.
DAE has multiple diagnostic and therapeutic applications, the most common being the evaluation of overt and occult SSBB, suspected SB CD, and SB tumors. To increase diagnostic and therapeutic yields while performing DAE safely and effectively, selection of an appropriate insertion route based on the results of antecedent diagnostic studies and insufflation with CO2 are needed. Most endoscopic therapeutic interventions performed in duodenoscopy and colonoscopy, including hemostasis, balloon dilatation, and polypectomy, can be safely and effectively performed in DAE.
We have made our best efforts to provide the most appropriate recommendations for the real practice of DAE based on the available evidence at the time of review. These expert statements should be interpreted considering specific clinical situations and available resources. In addition, these statements might be revised as technical innovations emerge, and further controlled clinical studies should be conducted.

Funding Source

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of Interest

Myung SJ is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.

Data Availability Statement

Not applicable.

Author Contribution

Conceptualization: Myung SJ, Jeon SR. Data curation: Lee HH, Goong HJ. Formal analysis: Lee HH, Goong HJ, Jeon SR. Methodology: Lee HH, Goong HJ, Lee SH, Oh EH, Park J, Kim MC, Nam K, Yang YJ, Kim TJ, Nam SJ, Moon HS, Kim JH, Kim DH, Kim SE, Kim JS. Project administration: Lee HH, Jeon SR, Myung SJ. Resources: Kim JS, Jeon SR. Supervision: Jeon SR, Myung SJ. Validation: Lee HH, Goong HJ, Lee SH, Oh EH, Park J, Kim MC, Nam K, Yang YJ, Kim TJ, Nam SJ, Moon HS, Kim JH, Kim DH, Kim SE, Kim JS, Jeon SR. Visualization: Lee HH, Goong HJ, Jeon SR. Writing - original draft: Lee HH, Goong HJ, Lee SH, Oh EH, Park J, Kim MC, Nam K, Yang YJ, Kim TJ, Nam SJ, Moon HS, Kim JH, Kim DH, Kim SE, Kim JS, Jeon SR. Writing - review & editing: Lee HH, Goong HJ, Lee SH, Oh EH, Park J, Kim MC, Nam K, Yang YJ, Kim TJ, Nam SJ, Moon HS, Kim JH, Kim DH, Kim SE, Kim JS, Jeon SR, Myung SJ. Approval of final manuscript: all authors.

Non-Author Contribution

The authors thank Ph.D. Miyoung Choi from a National Evidence-based Healthcare Collaborating Agency for advice on Delphi method.

Table 1.
Consensus Statements on the Use of Device-Assisted Enteroscopy by KASID
Accepted statements Strength of agreement (mean) SD CV
1. Diagnostic yield can be increased by performing DAE after CE in overt and occult suspected small bowel bleeding (SSBB). DAE can be considered following CE or contrast-enhanced computed tomography (CT) in overt and occult SSBB. 8.3 0.59 0.07
2. In cases of overt SSBB, early DAE can be considered after CE or contrast-enhanced CT to improve diagnostic yield and provide a chance for therapeutic intervention. 7.9 0.75 0.09
3. DAE is not a routine diagnostic test in patients with clinically suspected Crohn’s disease (CD). However, if there is no specific finding in the ileo-colonoscopy or other imaging studies, and results of laboratory tests alone are insufficient to diagnose CD in patients with suspected SB CD, SB tissue biopsy through DAE can be considered for enhancing confirmative diagnosis. 7.9 0.86 0.11
4. DAE can be considered for the localization and characterization of SB tumors along with other imaging modalities. 7.6 0.70 0.09
5. DAE may be used in symptomatic patients with intestinal polyposis causing obstruction and bleeding. Also, DAE may be used for the diagnosis and follow-up of some intestinal polyposis syndromes, particularly Peutz-Jeghers syndrome (PJS) rather than familial adenomatous polyposis (FAP). 7.8 0.88 0.11
6. In patients with suspected SB tumors, DAE can be considered for definite histologic diagnosis, identification of the extent and location of SB tumors, and therapeutic interventions to tailor appropriate treatment strategies. 7.9 0.86 0.11
7. In surgically altered anatomy, DAE enables examinations of parts of the intestinal lumen that are inaccessible to conventional and CE approaches and facilitates endoscopic retrograde cholangiopancreatography (ERCP). 7.9 0.78 0.10
8. The use of carbon dioxide insufflation rather than air insufflation improves intubation depth and increases patient convenience. 8.2 0.75 0.09
9. Although the majority of patients with SB lesions can be diagnosed without TE, TE could be considered in patients with negative CE findings and high clinical suspicion for a significant SB lesion, or in patients with lesions that are difficult to detect by a single approach. 7.6 0.62 0.08
10. The results of diagnostic studies prior to DAE and the clinical presentation should be considered in determining the insertion route. 8.4 0.80 0.09
11. Generally, the transoral approach is the preferred insertion route if the location of the lesion is uncertain from the previous diagnostic investigations. However, the insertion route should be determined considering the overall clinical situation. 7.8 0.66 0.09
12. Endoscopic hemostasis is recommended for achieving bleeding control and the hemostatic method should be selected according to the bleeding lesion. 7.9 0.83 0.10
13. Endoscopic balloon dilatation (EBD) using DAE in symptomatic benign SB stricture is reasonably safe and effective. 7.5 0.72 0.10
14. Enteroscopic polypectomy is recommended for the removal of large SB polyps to prevent polyp-related complications. 7.9 0.70 0.09
15. Although caution is required according to the patient’s condition and indications, DAE is considered a safe procedure. 7.7 0.69 0.09

The response scale is a 9-Likert scale, ranging from 1 point (strongly disagree) to 9 points (strongly agree), and the closer the score is to 9, the higher the strength of agreement.

KASID, Korean Association for the Study of Intestinal Diseases; DAE, device-assisted enteroscopy; CE, capsule endoscopy; SB, small bowel; TE, total enteroscopy; SD, standard deviation; CV, coefficient of variation (SD/mean).

  • 1. Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000;405:417.ArticlePDF
  • 2. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001;53:216–220.ArticlePubMed
  • 3. Jeon SR, Kim JO. Deep enteroscopy: which technique will survive? Clin Endosc 2013;46:480–485.ArticlePubMedPMCPDF
  • 4. Nair R, Aggarwal R, Khanna D. Methods of formal consensus in classification/diagnostic criteria and guideline development. Semin Arthritis Rheum 2011;41:95–105.ArticlePubMedPMC
  • 5. Hong KS, Ko SB, Yu KH, et al. Update of the Korean clinical practice guidelines for endovascular recanalization therapy in patients with acute ischemic stroke. J Stroke 2016;18:102–113.ArticlePubMedPMCPDF
  • 6. Pennazio M, Spada C, Eliakim R, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015;47:352–376.ArticlePubMed
  • 7. Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol 2015;110:1265–1287.ArticlePubMedPDF
  • 8. ASGE Standards of Practice Committee; Gurudu SR, Bruining DH, et al. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc 2017;85:22–31.ArticlePubMed
  • 9. Gralnek IM. Obscure-overt gastrointestinal bleeding. Gastroenterology 2005;128:1424–1430.ArticlePubMed
  • 10. Brito HP, Ribeiro IB, de Moura DT, et al. Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: a systematic review and meta-analysis. World J Gastrointest Endosc 2018;10:400–421.ArticlePubMedPMC
  • 11. Ohmiya N, Yano T, Yamamoto H, et al. Diagnosis and treatment of obscure GI bleeding at double balloon endoscopy. Gastrointest Endosc 2007;66(3 Suppl): S72–S77.ArticlePubMed
  • 12. Tanaka S, Mitsui K, Yamada Y, et al. Diagnostic yield of double-balloon endoscopy in patients with obscure GI bleeding. Gastrointest Endosc 2008;68:683–691.ArticlePubMed
  • 13. Fujita M, Manabe N, Honda K, et al. Long-term outcome after double-balloon endoscopy in patients with obscure gastrointestinal bleeding. Digestion 2010;82:173–178.ArticlePubMedPDF
  • 14. Ooka S, Kobayashi K, Kawagishi K, et al. Roles of capsule endoscopy and single-balloon enteroscopy in diagnosing unexplained gastrointestinal bleeding. Clin Endosc 2016;49:56–60.ArticlePubMedPMCPDF
  • 15. Hashimoto R, Matsuda T, Nakahori M. False-negative double-balloon enteroscopy in overt small bowel bleeding: long-term follow-up after negative results. Surg Endosc 2019;33:2635–2641.ArticlePubMedPDF
  • 16. Liu Y, Jiang W, Chen G, Li Y. Diagnostic value and safety of emergency single-balloon enteroscopy for obscure gastrointestinal bleeding. Gastroenterol Res Pract 2019;2019:9026278.ArticlePubMedPMCPDF
  • 17. Silva JC, Pinho R, Ponte A, et al. Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding? Scand J Gastroenterol 2020;55:1243–1247.ArticlePubMed
  • 18. Yin A, Zhao L, Ding Y, Yu H. Emergent double balloon enteroscopy in overt suspected small bowel bleeding: diagnosis and therapy. Med Sci Monit 2020;26:e920555.ArticlePubMedPMC
  • 19. Pinto-Pais T, Pinho R, Rodrigues A, et al. Emergency single-balloon enteroscopy in overt obscure gastrointestinal bleeding: efficacy and safety. United European Gastroenterol J 2014;2:490–496.ArticlePubMedPMCPDF
  • 20. Aniwan S, Viriyautsahakul V, Rerknimitr R, et al. Urgent double balloon endoscopy provides higher yields than non-urgent double balloon endoscopy in overt obscure gastrointestinal bleeding. Endosc Int Open 2014;2:E90–E95.ArticlePubMedPMC
  • 21. Hussan H, Crews NR, Geremakis CM, Bahna S, LaBundy JL, Hachem C. Predictors of double balloon endoscopy outcomes in the evaluation of gastrointestinal bleeding. World J Gastrointest Endosc 2014;6:248–253.ArticlePubMedPMC
  • 22. Mönkemüller K, Neumann H, Meyer F, Kuhn R, Malfertheiner P, Fry LC. A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding. Endoscopy 2009;41:715–717.ArticlePubMed
  • 23. Pérez-Cuadrado Robles E, Bebia Conesa P, Esteban Delgado P, et al. Emergency double-balloon enteroscopy combined with real-time viewing of capsule endoscopy: a feasible combined approach in acute overt-obscure gastrointestinal bleeding? Dig Endosc 2015;27:338–344.PubMed
  • 24. Pinho R, Ponte A, Rodrigues A, et al. Long-term rebleeding risk following endoscopic therapy of small-bowel vascular lesions with device-assisted enteroscopy. Eur J Gastroenterol Hepatol 2016;28:479–485.ArticlePubMed
  • 25. Ponte A, Pérez-Cuadrado Robles E, Pinho R, et al. High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding. Rev Esp Enferm Dig 2018;110:88–93.ArticlePubMed
  • 26. Gerson LB, Batenic MA, Newsom SL, Ross A, Semrad CE. Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding. Clin Gastroenterol Hepato 2009;7:664–669.Article
  • 27. Shelnut DJ, Sims OT, Zaibaq JN, Oh H, Venkata KV, Peter S. Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience. Endosc Int Open 2018;6:E751–E757.ArticlePubMedPMC
  • 28. Prachayakul V, Deesomsak M, Aswakul P, Leelakusolvong S. The utility of single-balloon enteroscopy for the diagnosis and management of small bowel disorders according to their clinical manifestations: a retrospective review. BMC Gastroenterol 2013;13:103.ArticlePubMedPMCPDF
  • 29. Teshima CW, Kuipers EJ, van Zanten SV, Mensink PB. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol 2011;26:796–801.ArticlePubMed
  • 30. Santhakumar C, Liu K. Evaluation and outcomes of patients with obscure gastrointestinal bleeding. World J Gastrointest Pathophysiol 2014;5:479–486.ArticlePubMedPMC
  • 31. Williamson JB, Judah JR, Gaidos JK, et al. Prospective evaluation of the long-term outcomes after deep small-bowel spiral enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2012;76:771–778.ArticlePubMed
  • 32. Vakil N, Huilgol V, Khan I. Effect of push enteroscopy on transfusion requirements and quality of life in patients with unexplained gastrointestinal bleeding. Am J Gastroenterol 1997;92:425–428.PubMed
  • 33. Jeon SR, Byeon JS, Jang HJ, et al. Clinical outcome after enteroscopy for small bowel angioectasia bleeding: a Korean Associateion for the Study of Intestinal Disease (KASID) multiceter study. J Gastroenterol Hepatol 2017;32:388–394.ArticlePubMedPDF
  • 34. Pérez-Cuadrado Robles E, Perrod G, Moreels TG, et al. A comprehensive systematic review and meta-analysis of risk factors for rebleeding following device-assisted enteroscopy therapy of small-bowel vascular lesions. Rev Esp Enferm Dig 2020;112:249–257.ArticlePubMed
  • 35. Yamamoto H, Ogata H, Matsumoto T, et al. Clinical practice guideline for enteroscopy. Dig Endosc 2017;29:519–546.ArticlePubMedPDF
  • 36. Shim KN, Moon JS, Chang DK, et al. Guideline for capsule endoscopy: obscure gastrointestinal bleeding. Clin Endosc 2013;46:45–53.ArticlePubMedPMCPDF
  • 37. Pérez-Cuadrado-Robles E, Pinho R, Gonzalez B, et al. Small bowel enteroscopy: a Joint Clinical Guideline from the Spanish and Portuguese Small Bowel Study Groups. GE Port J Gastroenterol 2020;27:324–335.ArticlePubMedPMCPDF
  • 38. Gomes C, Pinho R, Ponte A, Estevinho MM, Carvalho J. Timing of enteroscopy in overt-obscure gastrointestinal bleeding: a systematic review and meta-analysis. Rev Esp Enferm Dig 2021;113:656–669.ArticlePubMed
  • 39. Park SH, Kim YJ, Rhee KH, et al. A 30-year trend analysis in the epidemiology of inflammatory bowel disease in the Songpa-Kangdong district of Seoul, Korea in 1986-2015. J Crohns Colitis 2019;13:1410–1417.ArticlePubMedPDF
  • 40. Mensink PB, Groenen MJ, van Buuren HR, Kuipers EJ, van der Woude CJ. Double-balloon enteroscopy in Crohn’s disease patients suspected of small bowel activity: findings and clinical impact. J Gastroenterol 2009;44:271–276.ArticlePubMedPDF
  • 41. Rahman A, Ross A, Leighton JA, et al. Double-balloon enteroscopy in Crohn’s disease: findings and impact on management in a multicenter retrospective study. Gastrointest Endosc 2015;82:102–107.ArticlePubMed
  • 42. Jang HJ, Choi MH, Eun CS, et al. Clinical usefulness of double balloon enteroscopy in suspected Crohn’s disease: the KASID multi-center trial. Hepatogastroenterology 2014;61:1292–1296.PubMed
  • 43. Navaneethan U, Vargo JJ, Menon KV, Sanaka MR, Tsai CJ. Impact of balloon-assisted enteroscopy on the diagnosis and management of suspected and established small-bowel Crohn’s disease. Endosc Int Open 2014;2:E201–E206.ArticlePubMedPMC
  • 44. Bourreille A, Ignjatovic A, Aabakken L, et al. Role of small-bowel endoscopy in the management of patients with inflammatory bowel disease: an international OMED-ECCO consensus. Endoscopy 2009;41:618–637.ArticlePubMed
  • 45. Maaser C, Sturm A, Vavricka SR, et al. ECCO-ESGAR guideline for diagnostic assessment in IBD Part 1: initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019;13:144–164.ArticlePubMed
  • 46. Schulz C, Mönkemüller K, Salheiser M, Bellutti M, Schütte K, Malfertheiner P. Double-balloon enteroscopy in the diagnosis of suspected isolated Crohn’s disease of the small bowel. Dig Endosc 2014;26:236–242.ArticlePubMed
  • 47. Tontini GE, Vecchi M, Neurath MF, Neumann H. Advanced endoscopic imaging techniques in Crohn’s disease. J Crohns Colitis 2014;8:261–269.ArticlePubMed
  • 48. Oshitani N, Yukawa T, Yamagami H, et al. Evaluation of deep small bowel involvement by double-balloon enteroscopy in Crohn’s disease. Am J Gastroenterol 2006;101:1484–1489.ArticlePubMed
  • 49. Arulanandan A, Dulai PS, Singh S, Sandborn WJ, Kalmaz D. Systematic review: safety of balloon assisted enteroscopy in Crohn’s disease. World J Gastroenterol 2016;22:8999–9011.ArticlePubMedPMC
  • 50. Heine GD, Hadithi M, Groenen MJ, Kuipers EJ, Jacobs MA, Mulder CJ. Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease. Endoscopy 2006;38:42–48.ArticlePubMed
  • 51. Murphy SJ, Kornbluth A. Double balloon enteroscopy in Crohn’s disease: where are we now and where should we go? Inflamm Bowel Dis 2011;17:485–490.ArticlePubMed
  • 52. Vuori JV, Vuorio MK. Radiological findings in primary malignant tumours of the small intestine. Ann Clin Res 1971;3:16–21.PubMed
  • 53. Ekberg O, Ekholm S. Radiography in primary tumors of the small bowel. Acta Radiol Diagn (Stockh) 1980;21:79–84.ArticlePubMedPDF
  • 54. Honda W, Ohmiya N, Hirooka Y, et al. Enteroscopic and radiologic diagnoses, treatment, and prognoses of small-bowel tumors. Gastrointest Endosc 2012;76:344–354.ArticlePubMed
  • 55. Zagorowicz ES, Pietrzak AM, Wronska E, et al. Small bowel tumors detected and missed during capsule endoscopy: single center experience. World J Gastroenterol 2013;19:9043–9048.ArticlePubMedPMC
  • 56. Ross A, Mehdizadeh S, Tokar J, et al. Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy. Dig Dis Sci 2008;53:2140–2143.ArticlePubMedPDF
  • 57. Amzallag-Bellenger E, Oudjit A, Ruiz A, Cadiot G, Soyer PA, Hoeffel CC. Effectiveness of MR enterography for the assessment of small-bowel diseases beyond Crohn disease. Radiographics 2012;32:1423–1444.ArticlePubMed
  • 58. Sulbaran M, de Moura E, Bernardo W, et al. Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis. Endosc Int Open 2016;4:E151–E163.ArticlePubMedPMC
  • 59. Pasha SF, Leighton JA, Das A, et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis. Clin Gastroenterol Hepatol 2008;6:671–676.ArticlePubMed
  • 60. Mitsui K, Tanaka S, Yamamoto H, et al. Role of double-balloon endoscopy in the diagnosis of small-bowel tumors: the first Japanese multicenter study. Gastrointest Endosc 2009;70:498–504.ArticlePubMed
  • 61. Yamamoto H. Fifteen years since the advent of double-balloon endoscopy. Clin Gastroenterol Hepatol 2017;15:1647–1650.ArticlePubMed
  • 62. Schulmann K, Hollerbach S, Kraus K, et al. Feasibility and diagnostic utility of video capsule endoscopy for the detection of small bowel polyps in patients with hereditary polyposis syndromes. Am J Gastroenterol 2005;100:27–37.ArticlePubMed
  • 63. Rahmi G, Samaha E, Lorenceau-Savale C, et al. Small bowel polypectomy by double balloon enteroscopy: correlation with prior capsule endoscopy. World J Gastrointest Endosc 2013;5:219–225.ArticlePubMedPMC
  • 64. Ohmiya N, Nakamura M, Takenaka H, et al. Management of small-bowel polyps in Peutz-Jeghers syndrome by using enteroclysis, double-balloon enteroscopy, and videocapsule endoscopy. Gastrointest Endosc 2010;72:1209–1216.ArticlePubMed
  • 65. Goverde A, Korsse SE, Wagner A, et al. Small-bowel surveillance in patients with Peutz-Jeghers syndrome: comparing magnetic resonance enteroclysis and double balloon enteroscopy. J Clin Gastroenterol 2017;51:e27–e33.PubMed
  • 66. Beggs AD, Latchford AR, Vasen HF, et al. Peutz-Jeghers syndrome: a systematic review and recommendations for management. Gut 2010;59:975–986.ArticlePubMed
  • 67. Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328–333.ArticlePubMed
  • 68. Serrano M, Mão-de-Ferro S, Pinho R, et al. Double-balloon enteroscopy in the management of patients with Peutz-Jeghers syndrome: a retrospective cohort multicenter study. Rev Esp Enferm Dig 2013;105:594–599.ArticlePubMed
  • 69. Wang YX, Bian J, Zhu HY, et al. The role of double-balloon enteroscopy in reducing the maximum size of polyps in patients with Peutz-Jeghers syndrome: 12-year experience. J Dig Dis 2019;20:415–420.ArticlePubMedPDF
  • 70. Matsumoto T, Esaki M, Yanaru-Fujisawa R, et al. Small-intestinal involvement in familial adenomatous polyposis: evaluation by double-balloon endoscopy and intraoperative enteroscopy. Gastrointest Endosc 2008;68:911–919.ArticlePubMed
  • 71. Sulbaran M, Campos FG, Ribeiro U Jr, et al. Risk factors for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis: a prospective, single-center study. Endosc Int Open 2018;6:E531–E540.ArticlePubMedPMC
  • 72. Alderlieste YA, Rauws EA, Mathus-Vliegen EM, Fockens P, Dekker E. Prospective enteroscopic evaluation of jejunal polyposis in patients with familial adenomatous polyposis and advanced duodenal polyposis. Fam Cancer 2013;12:51–56.ArticlePubMedPDF
  • 73. Robles EP, Delgado PE, Conesa PB, et al. Role of double-balloon enteroscopy in malignant small bowel tumors. World J Gastrointest Endosc 2015;7:652–658.ArticlePubMedPMC
  • 74. Almeida N, Figueiredo P, Lopes S, Gouveia H, Leitão MC. Double-balloon enteroscopy and small bowel tumors: a South-European single-center experience. Dig Dis Sci 2009;54:1520–1524.ArticlePubMedPDF
  • 75. Rossi RE, Conte D, Elli L, Branchi F, Massironi S. Endoscopic techniques to detect small-bowel neuroendocrine tumors: a literature review. United European Gastroenterol J 2017;5:5–12.ArticlePubMedPMCPDF
  • 76. Chen WG, Shan GD, Zhang H, et al. Double-balloon enteroscopy in small bowel diseases: eight years single-center experience in China. Medicine (Baltimore) 2016;95:e5104.PubMedPMC
  • 77. Nakano A, Nakamura M, Watanabe O, et al. Endoscopic characteristics, risk grade, and prognostic prediction in gastrointestinal stromal tumors of the small bowel. Digestion 2017;95:122–131.ArticlePubMedPDF
  • 78. Safatle-Ribeiro AV, Ribeiro U Jr. Impact of enteroscopy on diagnosis and management of small bowel tumors. Chin J Cancer Res 2020;32:319–333.ArticlePubMedPMC
  • 79. Gangi A, Siegel E, Barmparas G, et al. Multifocality in small bowel neuroendocrine tumors. J Gastrointest Surg 2018;22:303–309.ArticlePubMedPDF
  • 80. Nishimura N, Mizuno M, Shimodate Y, et al. The role of double-balloon enteroscopy in the diagnosis and surgical treatment of metastatic small bowel tumors. Intern Med 2018;57:1209–1212.ArticlePubMedPMC
  • 81. Islam RS, Leighton JA, Pasha SF. Evaluation and management of small-bowel tumors in the era of deep enteroscopy. Gastrointest Endosc 2014;79:732–740.ArticlePubMed
  • 82. Ross AS, Semrad C, Waxman I, Dye C. Enteral stent placement by double balloon enteroscopy for palliation of malignant small bowel obstruction. Gastrointest Endosc 2006;64:835–837.ArticlePubMed
  • 83. Lee BI, Choi H, Choi KY, et al. Clinical characteristics of small bowel tumors diagnosed by double-balloon endoscopy: KASID multi-center study. Dig Dis Sci 2011;56:2920–2927.ArticlePubMedPDF
  • 84. Skinner M, Peter S, Wilcox CM, Mönkemüller K. Diagnostic and therapeutic utility of double-balloon enteroscopy for obscure GI bleeding in patients with surgically altered upper GI anatomy. Gastrointest Endosc 2014;80:181–186.ArticlePubMed
  • 85. Keren D, Madi H, Matter I, Assalia A, Rainis T. Feasibility and importance of enteroscopy after gastric bypass. Obes Surg 2017;27:1309–1315.ArticlePubMedPDF
  • 86. Kim DH, Byeon JS, Lee SK, et al. Usefulness of double balloon endoscopy in patients with surgically distorted intestinal anatomy. J Clin Gastroenterol 2009;43:737–742.ArticlePubMed
  • 87. Haber GB. Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos). Gastrointest Endosc 2007;66(3 Suppl): S47–S50.ArticlePubMed
  • 88. Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 2014;46:560–572.ArticlePubMed
  • 89. Gerson LB, Tokar J, Chiorean M, et al. Complications associated with double balloon enteroscopy at nine US centers. Clin Gastroenterol Hepatol 2009;7:1177–1182.ArticlePubMed
  • 90. Domagk D, Bretthauer M, Lenz P, et al. Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial. Endoscopy 2007;39:1064–1067.ArticlePubMed
  • 91. Li X, Zhao YJ, Dai J, et al. Carbon dioxide insufflation improves the intubation depth and total enteroscopy rate in single-balloon enteroscopy: a randomised, controlled, double-blind trial. Gut 2014;63:1560–1565.ArticlePubMed
  • 92. Nishizawa T, Suzuki H, Fujimoto A, Ochiai Y, Kanai T, Naohisa Y. Effects of carbon dioxide insufflation in balloon-assisted enteroscopy: a systematic review and meta-analysis. United European Gastroenterol J 2016;4:11–17.ArticlePubMedPMCPDF
  • 93. Hirai F, Beppu T, Nishimura T, et al. Carbon dioxide insufflation compared with air insufflation in double-balloon enteroscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc 2011;73:743–749.ArticlePubMed
  • 94. Takano N, Yamada A, Watabe H, et al. Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial. Gastrointest Endosc 2011;73:734–739.ArticlePubMed
  • 95. May A, Färber M, Aschmoneit I, et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010;105:575–581.ArticlePubMedPDF
  • 96. Xin L, Liao Z, Jiang YP, Li ZS. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc 2011;74:563–570.ArticlePubMed
  • 97. Domagk D, Mensink P, Aktas H, et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial. Endoscopy 2011;43:472–476.ArticlePubMed
  • 98. Wadhwa V, Sethi S, Tewani S, et al. A meta-analysis on efficacy and safety: single-balloon vs. double-balloon enteroscopy. Gastroenterol Rep (Oxf) 2015;3:148–155.ArticlePubMedPMC
  • 99. Beyna T, Arvanitakis M, Schneider M, et al. Total motorized spiral enteroscopy: first prospective clinical feasibility trial. Gastrointest Endosc 2021;93:1362–1370.ArticlePubMed
  • 100. Lenz P, Domagk D. Double- vs. single-balloon vs. spiral enteroscopy. Best Pract Res Clin Gastroenterol 2012;26:303–313.ArticlePubMed
  • 101. May A. How much importance do we have to place on complete enteroscopy? Gastrointest Endosc 2011;73:740–742.ArticlePubMed
  • 102. Xin L, Gao Y, Liao Z, Li ZS. The reasonable calculation of complete enteroscopy rate for balloon-assisted enteroscopy. Endoscopy 2011;43:832.ArticlePubMed
  • 103. Gerson LB. Small-bowel enteroscopy. Endoscopy 2013;45:292–295.ArticlePubMed
  • 104. Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by double-balloon endoscopy. Gastrointest Endosc 2014;80:112–117.ArticlePubMed
  • 105. Hashimoto R, Nakahori M, Matsuda T. Impact of urgent double-balloon enteroscopy on the short-term and long-term outcomes in overt small bowel bleeding. Dig Dis Sci 2019;64:2933–2938.ArticlePubMedPDF
  • 106. Shinozaki S, Yano T, Sakamoto H, et al. Long-term outcomes in patients with overt obscure gastrointestinal bleeding after negative double-balloon endoscopy. Dig Dis Sci 2015;60:3691–3696.ArticlePubMedPDF
  • 107. Chen X, Ran ZH, Tong JL. A meta-analysis of the yield of capsule endoscopy compared to double-balloon enteroscopy in patients with small bowel diseases. World J Gastroenterol 2007;13:4372–4378.ArticlePubMedPMC
  • 108. Bonnet S, Douard R, Malamut G, Cellier C, Wind P. Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. Dig Liver Dis 2013;45:277–284.ArticlePubMed
  • 109. Shim KN, Jeon SR, Jang HJ, et al. Quality indicators for small bowel capsule endoscopy. Clin Endosc 2017;50:148–160.ArticlePubMedPMCPDF
  • 110. Baek DH, Hwang S, Eun CS, et al. Factors affecting route selection of balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding: a KASID Multicenter Study. Diagnostics (Basel) 2021;11:1860.ArticlePubMedPMC
  • 111. Buscaglia JM, Okolo PI 3rd. Deep enteroscopy: training, indications, and the endoscopic technique. Gastrointest Endosc 2011;73:1023–1028.ArticlePubMed
  • 112. Gay G, Delvaux M, Fassler I. Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy. Endoscopy 2006;38:49–58.ArticlePubMed
  • 113. Rondonotti E, Spada C, Adler S, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2018;50:423–446.ArticlePubMed
  • 114. Teshima CW, Aktas H, van Buuren HR, Kuipers EJ, Mensink PB. Retrograde double balloon enteroscopy: comparing performance of solely retrograde versus combined same-day anterograde and retrograde procedure. Scand J Gastroenterol 2011;46:220–226.ArticlePubMed
  • 115. Shinozaki S, Yamamoto H, Yano T, et al. Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy. Clin Gastroenterol Hepatol 2010;8:151–158.ArticlePubMed
  • 116. Sanaka MR, Navaneethan U, Kosuru B, Yerneni H, Lopez R, Vargo JJ. Antegrade is more effective than retrograde enteroscopy for evaluation and management of suspected small-bowel disease. Clin Gastroenterol Hepatol 2012;10:910–916.ArticlePubMed
  • 117. Akyüz Ü, Pata C, Kalayci M, et al. Route selection for double balloon enteroscopy in patients with obscure gastrointestinal bleeding: experience from a single center. Turk J Gastroenterol 2012;23:670–675.PubMed
  • 118. Kaffes AJ, Siah C, Koo JH. Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy. Gastrointest Endosc 2007;66:304–309.ArticlePubMed
  • 119. Hasan BM, McMahon C, Khalid RA, et al. Utility and safety of balloon-assisted enteroscopy in patients with left ventricular assist devices: a retrospective multicenter study. Endosc Int Open 2020;8:E1002–E1008.ArticlePubMedPMC
  • 120. Rodrigues JP, Pinho R, Rodrigues A, et al. Diagnostic and therapeutic yields of urgent balloon-assisted enteroscopy in overt obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol 2018;30:1304–1308.ArticlePubMed
  • 121. May A, Friesing-Sosnik T, Manner H, Pohl J, Ell C. Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding. Endoscopy 2011;43:759–765.ArticlePubMed
  • 122. Ikeya T, Ishii N, Shimamura Y, et al. Endoscopic band ligation for bleeding lesions in the small bowel. World J Gastrointest Endosc 2014;6:488–492.ArticlePubMedPMC
  • 123. Kamalaporn P, Cho S, Basset N, et al. Double-balloon enteroscopy following capsule endoscopy in the management of obscure gastrointestinal bleeding: outcome of a combined approach. Can J Gastroenterol 2008;22:491–495.ArticlePubMedPMCPDF
  • 124. Kida A, Matsuda K, Hirai S, et al. A pedunculated polyp-shaped small-bowel lymphangioma causing gastrointestinal bleeding and treated by double-balloon enteroscopy. World J Gastroenterol 2012;18:4798–4800.ArticlePubMedPMC
  • 125. Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140:1785–1794.ArticlePubMed
  • 126. Alexander-Williams J, Haynes IG. Conservative operations for Crohn’s disease of the small bowel. World J Surg 1985;9:945–951.ArticlePubMedPDF
  • 127. Lee EC, Papaioannou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 1982;64:229–233.PubMedPMC
  • 128. Navaneethan U, Lourdusamy V, Njei B, Shen B. Endoscopic balloon dilation in the management of strictures in Crohn’s disease: a systematic review and meta-analysis of non-randomized trials. Surg Endosc 2016;30:5434–5443.ArticlePubMedPDF
  • 129. Fukumoto A, Tanaka S, Yamamoto H, et al. Diagnosis and treatment of small-bowel stricture by double balloon endoscopy. Gastrointest Endosc 2007;66(3 Suppl): S108–S112.ArticlePubMed
  • 130. Sunada K, Shinozaki S, Nagayama M, et al. Long-term outcomes in patients with small intestinal strictures secondary to Crohn’s disease after double-balloon endoscopy-assisted balloon dilation. Inflamm Bowel Dis 2016;22:380–386.ArticlePubMed
  • 131. Hirai F, Andoh A, Ueno F, et al. Efficacy of endoscopic balloon dilation for small bowel strictures in patients with Crohn’s disease: a nationwide, multi-centre, open-label, prospective cohort study. J Crohns Colitis 2018;12:394–401.ArticlePubMed
  • 132. Bettenworth D, Bokemeyer A, Kou L, et al. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn’s disease strictures. Aliment Pharmacol Ther 2020;52:1104–1116.ArticlePubMedPMCPDF
  • 133. van Lier MG, Mathus-Vliegen EM, Wagner A, van Leerdam ME, Kuipers EJ. High cumulative risk of intussusception in patients with Peutz-Jeghers syndrome: time to update surveillance guidelines? Am J Gastroenterol 2011;106:940–945.ArticlePubMedPDF
  • 134. van Lier MG, Wagner A, Mathus-Vliegen EM, Kuipers EJ, Steyerberg EW, van Leerdam ME. High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations. Am J Gastroenterol 2010;105:1258–1264.ArticlePubMedPDF
  • 135. Koornstra JJ, Kleibeuker JH, Vasen HF. Small-bowel cancer in Lynch syndrome: is it time for surveillance? Lancet Oncol 2008;9:901–905.ArticlePubMed
  • 136. Perrod G, Samaha E, Perez-Cuadrado-Robles E, et al. Small bowel polyp resection using device-assisted enteroscopy in Peutz-Jeghers Syndrome: results of a specialised tertiary care centre. United European Gastroenterol J 2020;8:204–210.ArticlePubMedPMCPDF
  • 137. Mensink PB, Haringsma J, Kucharzik T, et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy 2007;39:613–615.ArticlePubMed
  • 138. Wang P, Wang Y, Dong Y, et al. Outcomes and safety of double-balloon enteroscopy in small bowel diseases: a single-center experience of 1531 procedures. Surg Endosc 2021;35:576–583.ArticlePubMedPDF
  • 139. Mönkemüller K, Weigt J, Treiber G, et al. Diagnostic and therapeutic impact of double-balloon enteroscopy. Endoscopy 2006;38:67–72.ArticlePubMed
  • 140. May A, Nachbar L, Pohl J, Ell C. Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol 2007;102:527–535.ArticlePubMed
  • 141. Gao H, van Lier MG, Poley JW, Kuipers EJ, van Leerdam ME, Mensink PB. Endoscopic therapy of small-bowel polyps by double-balloon enteroscopy in patients with Peutz-Jeghers syndrome. Gastrointest Endosc 2010;71:768–773.ArticlePubMed
  • 142. Sekiya M, Sakamoto H, Yano T, et al. Double-balloon endoscopy facilitates efficient endoscopic resection of duodenal and jejunal polyps in patients with familial adenomatous polyposis. Endoscopy 2021;53:517–521.ArticlePubMed
  • 143. Möschler O, May A, Müller MK, Ell C; German DBE Study Group. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011;43:484–489.ArticlePubMed
  • 144. Moeschler O, Mueller MK. Deep enteroscopy: indications, diagnostic yield and complications. World J Gastroenterol 2015;21:1385–1393.ArticlePubMedPMC
  • 145. Rondonotti E, Sunada K, Yano T, Paggi S, Yamamoto H. Double-balloon endoscopy in clinical practice: where are we now? Dig Endosc 2012;24:209–219.ArticlePubMed
  • 146. ASGE Technology Committee, DiSario JA, Petersen BT, et al. Enteroscopes. Gastrointest Endosc 2007;66:872–880.ArticlePubMed
  • 147. Pennazio M, Venezia L, Cortegoso Valdivia P, Rondonotti E. Device-assisted enteroscopy: an update on techniques, clinical indications and safety. Dig Liver Dis 2019;51:934–943.ArticlePubMed
  • 148. Judah JR, Draganov PV, Lam Y, Hou W, Buscaglia JM. Spiral enteroscopy is safe and effective for an elderly United States population of patients with numerous comorbidities. Clin Gastroenterol Hepatol 2010;8:572–576.ArticlePubMed
  • 149. Akerman PA, Cantero D. Spiral enteroscopy and push enteroscopy. Gastrointest Endosc Clin N Am 2009;19:357–369.ArticlePubMed
  • 150. Davis-Yadley AH, Lipka S, Rodriguez AC, et al. The safety and efficacy of single balloon enteroscopy in the elderly. Therap Adv Gastroenterol 2016;9:169–179.ArticlePubMedPMCPDF
  • 151. Byeon JS, Mann NK, Jamil LH, Lo SK. Double balloon enteroscopy can be safely done in elderly patients with significant co-morbidities. J Gastroenterol Hepatol 2012;27:1831–1836.ArticlePubMed
  • 152. Chavalitdhamrong D, Adler DG, Draganov PV. Complications of enteroscopy: how to avoid them and manage them when they arise. Gastrointest Endosc Clin N Am 2015;25:83–95.ArticlePubMed
  • 153. Zepeda-Gómez S, Barreto-Zuñiga R, Ponce-de-León S, et al. Risk of hyperamylasemia and acute pancreatitis after double-balloon enteroscopy: a prospective study. Endoscopy 2011;43:766–770.ArticlePubMed
  • 154. Kopácová M, Rejchrt S, Tachecí I, Bures J. Hyperamylasemia of uncertain significance associated with oral double-balloon enteroscopy. Gastrointest Endosc 2007;66:1133–1138.ArticlePubMed
  • 155. Kopacova M, Tacheci I, Rejchrt S, Bartova J, Bures J. Double balloon enteroscopy and acute pancreatitis. World J Gastroenterol 2010;16:2331–2340.ArticlePubMedPMC
  • 156. Möschler O, May AD, Müller MK, Ell C; DBE-Studiengruppe Deutschland. Complications in double-balloon-enteroscopy: results of the German DBE register. Z Gastroenterol 2008;46:266–270.PubMed

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      Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases
      Intest Res. 2023;21(1):3-19.   Published online January 31, 2023
      DOI: https://doi.org/10.5217/ir.2022.00108
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    Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases
    Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases
    Accepted statements Strength of agreement (mean) SD CV
    1. Diagnostic yield can be increased by performing DAE after CE in overt and occult suspected small bowel bleeding (SSBB). DAE can be considered following CE or contrast-enhanced computed tomography (CT) in overt and occult SSBB. 8.3 0.59 0.07
    2. In cases of overt SSBB, early DAE can be considered after CE or contrast-enhanced CT to improve diagnostic yield and provide a chance for therapeutic intervention. 7.9 0.75 0.09
    3. DAE is not a routine diagnostic test in patients with clinically suspected Crohn’s disease (CD). However, if there is no specific finding in the ileo-colonoscopy or other imaging studies, and results of laboratory tests alone are insufficient to diagnose CD in patients with suspected SB CD, SB tissue biopsy through DAE can be considered for enhancing confirmative diagnosis. 7.9 0.86 0.11
    4. DAE can be considered for the localization and characterization of SB tumors along with other imaging modalities. 7.6 0.70 0.09
    5. DAE may be used in symptomatic patients with intestinal polyposis causing obstruction and bleeding. Also, DAE may be used for the diagnosis and follow-up of some intestinal polyposis syndromes, particularly Peutz-Jeghers syndrome (PJS) rather than familial adenomatous polyposis (FAP). 7.8 0.88 0.11
    6. In patients with suspected SB tumors, DAE can be considered for definite histologic diagnosis, identification of the extent and location of SB tumors, and therapeutic interventions to tailor appropriate treatment strategies. 7.9 0.86 0.11
    7. In surgically altered anatomy, DAE enables examinations of parts of the intestinal lumen that are inaccessible to conventional and CE approaches and facilitates endoscopic retrograde cholangiopancreatography (ERCP). 7.9 0.78 0.10
    8. The use of carbon dioxide insufflation rather than air insufflation improves intubation depth and increases patient convenience. 8.2 0.75 0.09
    9. Although the majority of patients with SB lesions can be diagnosed without TE, TE could be considered in patients with negative CE findings and high clinical suspicion for a significant SB lesion, or in patients with lesions that are difficult to detect by a single approach. 7.6 0.62 0.08
    10. The results of diagnostic studies prior to DAE and the clinical presentation should be considered in determining the insertion route. 8.4 0.80 0.09
    11. Generally, the transoral approach is the preferred insertion route if the location of the lesion is uncertain from the previous diagnostic investigations. However, the insertion route should be determined considering the overall clinical situation. 7.8 0.66 0.09
    12. Endoscopic hemostasis is recommended for achieving bleeding control and the hemostatic method should be selected according to the bleeding lesion. 7.9 0.83 0.10
    13. Endoscopic balloon dilatation (EBD) using DAE in symptomatic benign SB stricture is reasonably safe and effective. 7.5 0.72 0.10
    14. Enteroscopic polypectomy is recommended for the removal of large SB polyps to prevent polyp-related complications. 7.9 0.70 0.09
    15. Although caution is required according to the patient’s condition and indications, DAE is considered a safe procedure. 7.7 0.69 0.09
    Table 1. Consensus Statements on the Use of Device-Assisted Enteroscopy by KASID

    The response scale is a 9-Likert scale, ranging from 1 point (strongly disagree) to 9 points (strongly agree), and the closer the score is to 9, the higher the strength of agreement.

    KASID, Korean Association for the Study of Intestinal Diseases; DAE, device-assisted enteroscopy; CE, capsule endoscopy; SB, small bowel; TE, total enteroscopy; SD, standard deviation; CV, coefficient of variation (SD/mean).

    Table 1.

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